What Are the Functional Results and Complications With Long Stem Hemiarthroplasty in Patients With Metastases to the Proximal Femur?

Abstract

Background Traditional treatments for pathological fractures of the proximal femur resulting from metastatic bone disease include fixation with intramedullary nailing supplemented with polymethylmethacrylate, osteosynthesis with a plate-screw construct and polymethylmethacrylate, or endoprosthetic reconstruction. Despite the frequent practice of these treatments, treatment outcomes have not been rigorously compared. In addition, very few studies examine specific approaches to endoprosthetic reconstruction such as long stem hemiarthroplasty.Questions/purposes This study examines survival, functional outcomes, and complications associated with long stem hemiarthroplasty in a small group of patients treated for impending and actual pathologic fractures of the proximal femur resulting from metastatic bone disease. Methods Between 2012 and 2015, 21 patients were treated with long stem cemented hemiarthroplasty in 22 limbs. During that time, indications for this approach included lesions from metastases, myeloma, or lymphoma involving the proximal femur that resulted in an impending or actual pathological fracture. An impending fracture was classified as a painful lesion with at least 50% cortical erosion. During the study period, six patients with proximal femoral metastases not deemed to meet these indications were treated with other surgical approaches such as intramedullary nailing supplemented with polymethylmethacrylate and osteosynthesis with a plate-screw construct and polymethylmethacrylate. Mortality was tracked through medical records and phone calls to the patients and their families. Followup for the entire group of patients (n = 22) ranged from 1 to 27 months with a mean duration of 11 months. For patients with at least 1 year of followup (n = 11), the mean duration was 18 months (range, 12-27 months) and for patients with less than 1 year of followup (n = 11), the mean duration was 3 months (range, 1-11 months). Functional outcomes were evaluated according to the Musculoskeletal Tumor Society (MSTS) scoring system for lower extremities, the Eastern Cooperative Oncology Group (ECOG) Scale of Performance Status, and the Karnofsky Performance Scale (KPS) Index. Scores and complications were determined by direct patient examination, retrospective chart review, review of a longitudinally maintained institutional database, and followup phone calls. Results Ten patients died of disease within the followup period. Before surgery, the median total MSTS score for the entire group of patients (n = 22) was 4.5 (range, 0-23), Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research1 editors and board members are on file with the publication and can be viewed on request. Clinical O...

Prediction of survival after surgical management of femoral metastatic bone disease – A comparison of prognostic models

“…However, all prognostic models except OPTIModel included multiple myeloma and lymphoma it the assessment of patient survival. These haematological malignancies cause pathological fractures of the femur requiring orthopaedic management [3], [13], [14], [15], [16], [35], [36]. This analysis included multiple myeloma and lymphoma primary cancer types in the femoral MBD patient dataset.…”

Use of endoprostheses for proximal femur metastases results in a rapid rehabilitation and low risk of implant failure. A prospective population-based study

“…These scores are very comparable and it may be that no benefit from further rehabilitation is gained over time or, more likely, the ceiling effect of the MSTS score is achieved already 6 months postoperatively, and therefore other questionnaires should be used instead in future studies to address gain in functional outcome over time. Peterson et al [31] have a similar way of presenting their data, regarding patients undergoing long-stemmed hemiarthroplasty for MBDf, and report above or below one year follow-up, but again not with exact follow-up period in these two categories. They observe a gain in MSTS score over time with an average MSTS score of 27 for patients followed for more than one year after surgery.…”

“…The MSTS score did increase gradually over the first six months postoperatively for the endoprosthesis group, indicating the potential for improvement over time. Most studies reporting the MSTS score in MBDf patients undergoing surgery report the score as an average at clinical follow-up at any time after surgery [29], [30], [31], and this bias the outcome, as we do not know how many patients were scored 2 years after surgery or 2 weeks after surgery. Harvey et al [29] found no statistically significantly difference in MSTS score comparing treatment with internal fixation to endoprosthesis, but they also report that patients having internal fixation was followed on average of 20 months postoperatively compared to 14 months for the endoprosthesis group, allowing for further rehabilitation time for the internal fixation group, which potentially bias their reporting.…”

Metastatic Disease, Myeloma, and Lymphoma Affecting the Hip

“…Peterson et al evaluated the outcomes after utilization of a long stem hemiarthroplasty in the setting of bony metastasis of the proximal femur and found fair levels of postoperative function. 61 Steensma et al reported a significantly lower treatment failure rate and fewer revisions requiring implant exchange in patients who underwent endoprosthetic reconstruction when compared with open reduction-internal fixation and intramedullary nailing. 62 Janssen et al performed a retrospective study on the complications after the surgical management of proximal femoral metastasis.…”